The Comorbidity Between Epilepsy and Psychiatric Disorders: Assessing the Integration of Neuropsychiatric Care
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Impulse: The Premier Journal for Undergraduate Publications in the Neurosciences
2021
The Comorbidity Between Epilepsy and Psychiatric Disorders:
Assessing the Integration of Neuropsychiatric Care
Erin E. Reasoner, Elizabeth I. Flandreau
Grand Valley State University, Allendale, Michigan 49401
Psychiatric symptoms are extremely pervasive in epilepsy patient populations and represent a
significant burden on quality of life for people with epilepsy (PWE). Despite growing awareness
of this reality, mental illness (MI) in PWE continues to be under-diagnosed and under-treated.
Recent developments in our understanding of the bidirectional relationship between seizures and
psychopathology inform an increased need for collaboration of healthcare providers from
neurology and psychiatry disciplines. This article highlights present institutional barriers to
diagnosis and treatment of PWE with comorbid MI (PWE/MI), including poor interdisciplinary
communication, limited opportunities for cross-specialty training, and the arbitrary theoretical
divide between neurology and psychiatry, which distinguishes their approach to managing
complex brain disorders. We discuss recent progress towards improving quality of care, both
through advancements in our understanding of the common risk factors for epilepsy and MI and
through practical interventions, such as increased behavioral health screenings. While these
developments have demonstrated a positive impact on patient outcomes, there remains a clear need
for system-wide change.
Abbreviations: PWE/MI – people with epilepsy and comorbid mental illness; PWE – people with
epilepsy; EEG – electroencephalogram; AEDs – anti-epileptic drugs; PNES – psychogenic non-
epileptic seizures; MI – mental illness; ADHD – attention deficit-hyperactivity disorder
Keywords: epilepsy, psychiatric comorbidities, psychiatric complications, treatment-resistant
epilepsy, patient-centered, education, interdisciplinary collaboration, management, neurology,
psychiatry
Introduction
Epilepsy is the fourth most common al., 2021). Psychiatric symptoms can present as
neurological disorder in the United States, interictal (independent from seizure activity),
affecting 3.4 million individuals nationally (Hirtz peri-ictal (temporally related to seizure
et al., 2007). One in three people with epilepsy occurrence), or iatrogenic (linked to
(PWE) will also be diagnosed with a psychiatric pharmacological treatments) (Kanner, 2016a).
disorder at some point during their lifetime The existence of peri-ictal and iatrogenic
(Tellez-Zenteno et al., 2007). psychiatric symptoms suggests overlapping
The relationship between psychiatric neurobiological etiology for psychiatric and
symptoms and epilepsy takes many forms. Mood epileptic symptoms.
and anxiety disorders are the most reported Comorbidity between seizure and
psychiatric comorbidities in PWE (Lu et al., psychiatric disorders has a compounding impact
2021). However, psychosis, attention deficit- on health outcomes. Psychiatric illness
hyperactivity disorder (ADHD), and substance significantly increases risk of pharmacoresistant
use disorders are also reported at higher rates in epilepsy, recurring seizures, and early mortality
PWE, compared to the general population (Lu et in PWE (Petrovski et al., 2010; Hesdorffer et al.,Page 2 of 12
The Comorbidity Between Epilepsy and Psychiatric Disorders: Assessing the Integration of Neuropsychiatric Care
2021
2012; Fazel et al., 2013; Nogueira et al., 2017). example of this is a phenomenon of “forced
Furthermore, multiple studies have demonstrated normalization”, described by Landolt in 1953.
that psychiatric symptoms are a stronger While observing treatment of PWE, Landolt
predictor of quality of life than seizure-related reported that normalization of
variables (Johnson et al., 2004; Taylor et al., electroencephalogram (EEG) readings was
2011). frequently followed by onset of novel chronic
In part due to the extraordinary psychosis.
comorbidity across psychiatric and seizure
disorders, there is growing recognition of “There’s this terrible irony where sometimes if
epilepsy as a neuropsychiatric condition (Kanner, you normalize somebody’s EEG, their
2016b). It is crucial that our approach to care- psychiatric symptoms get worse. Sometimes
management addresses the interdependency of the side effects of the anti-epileptic
seizures and psychiatric symptoms in PWE. The medications are really bad and sometimes
present paper explores the challenges of people with brain disease just have really tough
diagnosing and treating PWE and comorbid symptoms.”
mental illness (PWE/MI) from a patient-centered - Gerald Scott Winder, MD. (Psychiatrist at
perspective. Michigan Medicine)
To provide a holistic assessment of Subsequent observations of forced
current epilepsy care management, we conducted normalization are increasingly rare and have
unstructured, qualitative interviews with epilepsy largely been attributed to certain anti-epileptic
care providers during the summer of 2020. All drugs (AED) (Clemens, 2005; Weber et al., 2012;
interviews were conducted virtually. Pre-written Topkan et al., 2016). However, even with modern
questions were individualized to the expertise of treatments, withdrawing medications does not
each provider. Relevant quotes were selected consistently resolve symptoms, suggesting a
after a review of the literature had been degree of innate biological antagonism between
completed. These anecdotes and experience are the pathology of seizures and psychopathologies
quoted throughout this review to provide context (Calle López et al., 2019).
to the literature.
“Does this mean that seizures have some kind
“If you think about neurological conditions – of weird treatment effect on improving
they are brain-based things, but so are psychiatric symptoms? If so, does the reverse
psychiatric conditions. We separate them hold true that if people have well-controlled
academically, but they do have quite a bit of seizures, are they at higher risk for depression?
overlap.” I definitely think there’s that dynamic there
- Hannah Wadsworth, PhD. and it’s really interesting.”
(Neuropsychologist at the University of - Nicolas Beimer, MD. (Epileptologist at
Iowa Hospital and Clinic) Michigan Medicine)
For many patients there appears to be a
Shared Etiology of Seizures and direct correlation between psychiatric symptoms
Psychiatric Symptoms and seizures. For example, current or past
diagnosis of depression predicts new-onset
epilepsy and failure to achieve seizure-freedom
The association between mental health
(Josephson et al., 2017). Furthermore, a large-
and epilepsy has been a matter of speculation for
scale comparison of data from FDA clinical trials
centuries (Kanner, 2000). Epilepsy is typically
found that treatment with antidepressants was
diagnosed via electroencephalogram (EEG),
associated with lower seizure incidence in later
which is used to detect abnormalities in
years (Josephson et al., 2017). History of
spontaneous intercranial electrical activity
depression, psychosis, or personality disorders is
(Miller et al, 2014). Historically, both clinicians
also implicated in post-operative seizure
and scientists posited that treating epilepsy could
reoccurrence in PWE treated with surgical
aggravate behavioral symptoms. The primaryPage 3 of 12
Impulse: The Premier Journal for Undergraduate Publications in the Neurosciences
2021
interventions (Kanner et al., 2009; de Araújo 400 different symptom combinations that satisfy
Filho et al., 2012; Koch Stoecker et al., 2017). diagnostic criteria for Major Depressive Disorder
The relationship between psychiatric and (MDD) alone and nearly 300 million possible
epileptic symptoms appears to be bidirectional, symptom combinations to diagnose comorbid
with an elevated incidence of psychiatric MDD and post-traumatic stress disorder (PTSD)
diagnoses reported both before and after epilepsy (Young et al., 2014). This immense diversity in
diagnosis (Hesdorffer et al., 2012). Among behavioral symptomology complicates both the
PWE/MI, resistance to AEDs predicts increased initial diagnosis of a psychiatric disorder and
severity of psychiatric symptoms (Petrovski et subsequent care management of psychiatric
al., 2010). Similarly, one study associated symptoms.
pharmacoresistance among epileptic rats with
heightened anxiety, hyperexcitability, and “It’s an open secret that sometimes we aren’t
cognitive deficits (Gastens et al., 2008). very good at treating psychiatric patients.
While the multifactorial nature of Basically, the whole thing can be just trial and
neurologic and psychiatric health makes it error because the brain is so poorly understood
difficult to demonstrate a direct causal compared to other parts of the body.”
relationship between epilepsy and psychiatric - Dr. Scott Winder (Psychiatrist)
comorbidities, these examples strongly indicate Ambiguity surrounding mental illness
that treating psychiatric comorbidities also contributes to lengthy diagnostic delays, often
improves seizure outcomes for PWE/MI. The measured in years or decades from symptom
relationship between epilepsy and psychiatric onset (Wang et al., 2004; Berg et al., 2014). In a
conditions remains largely uninvestigated and report from Mojtabai and colleagues, patients
poorly understood. Further scientific inquiry into cited structural barriers such as affordability,
the biological relationship between seizure physical accessibility, and shortages in treatment
activity and psychiatric symptom severity has providers as the most frequent causes of delay
significant potential for informing improvements (2014). While many of these difficulties lie at a
in care, and thus, quality of life for PWE. systematic level outside the control of individual
treatment providers, they nonetheless create an
Challenges Diagnosing Psychiatric additional burden for people with mental illness.
This unfortunately sets up the many PWE/MI
Disorders in PWE
with an exponential burden in pursuing treatment
for both conditions.
Psychiatric Diagnosis as a Moving Target
Diagnosis of psychiatric disorders uses a “One of the unfortunate realities of our
classification system primarily based on self- healthcare system is that we have long waits.
reported symptoms (Clark et al., 2017). As our In Iowa we have a lot of people in rural areas
understanding of mental illness and behavioral that don’t have easy access to [mental health
health evolves, so too do the classifications in the care]. It takes a lot of creative problem solving
Diagnostic and Statistical Manual of Mental and we do what we can to get them held over
Disorders (DSM). Fluidity in psychiatric until they can get the help they need.”
nosology accommodates a multimodal approach - Dr. Hannah Wadsworth
to treating psychological pathologies that exist on (Neuropsychologist)
a continuum (Allsopp et al., 2019); however, it
also results in a system that is extremely difficult Institutional Divide Between Neurology and
to navigate. Psychiatry
With each iteration of the DSM one of Presently, healthcare disciplines are
the primary challenges has been optimizing organized as silos in a fragmented system where
guidance for comorbid diagnoses (Pincus et al., individual specialists largely keep to themselves
2004). For instance, under the current (Tran et al., 2018). Although a recent push
classification system, the DSM-5, there are over prioritizes integrated care and greaterPage 4 of 12
The Comorbidity Between Epilepsy and Psychiatric Disorders: Assessing the Integration of Neuropsychiatric Care
2021
collaboration across specialties (Allen et al., “gold standard” for diagnosing PNES (Baslet et
2006), the historical barrier between psychiatry al., 2020).
and neurology lingers in hospitals and clinics.
Most epilepsy centers lack a psychiatrist, and “There are data suggesting that neurologists
while neuropsychologists are often included on are kind of mediocre in diagnosing [PNES] and
the care team for PWE, the focus is typically on there are also data that suggest psychiatrists
evaluating cognition and behavior, not mental don’t believe it’s a thing – how crazy is that?
health (Lopez et al., 2019). As a result, many So, all of this is to say that this population of
neurologists may be missing a crucial resource patients are poorly understood. They’re poorly
for informing care decisions, leaving PWE/MI taken care of, and the fault of that lies in both
with no clear path from their neurology clinic to specialties.”
treatment under a psychiatrist’s care. - Dr. Scott Winder (Psychiatrist)
“There are a lot of challenges – insurance Despite the widespread use of video EEG
challenges, geographic challenges, across tertiary epilepsy centers, the average
communication challenges – between mental diagnostic delay for PNES is estimated around
health and epilepsy providers.” seven to eight years from seizure onset (Reuber
- Dr. Nicholas Beimer (Epileptologist) et al., 2002; Kerr et al., 2016). Obstacles to timely
PNES treatment include stigma and insufficient
pathways for interdisciplinary care (LaFrance et
Psychogenic Non-Epileptic Seizures al., 2013; Smith, 2014; Baslet et al., 2015). Upon
(PNES): A Case-Study of Collaborative diagnosis of PNES, the patient is typically
Care transitioned to a behavioral health provider
Psychogenic non-epileptic seizures (Baslet et al., 2015; Benbadis, 2019). Yet,
(PNES) is a psychosomatic condition that psychiatrists report low confidence in the
presents identical to epilepsy (Johnsen and Ding, reliability of PNES diagnosis by vEEG (Harden
2020). However, psychogenic seizures are not et al., 2003). This may reflect a deficit of
associated with epileptiform brain activity. knowledge on epilepsy and PNES among
Instead, PNES is triggered by psychological psychiatrists or a strained working relationship
stress or emotional cues. Effectively diagnosing between neurology and psychiatry. Regardless,
and treating PNES demands that neurology and the discordance in specialist recommendations
psychiatry services coordinate. Examining leads to deficient care management, which,
clinical management of PNES can provide beyond causing further delays, often becomes
insight into the current status of integrated care. distressing for the patient and family.
PWE/MI share the same providers and
“[Treating PNES] takes time and it’s slow utilize the same services as individuals with
moving. I think part of the stigma that PNES. Thus, they are burdened with similar
surrounds somatic conditions is related to the treatment delays and challenges in integrating
difficulty providers have with finding the time care management. There remains a clear need to
needed [to treat these conditions bridge the divide between neurology and
appropriately].” psychiatry, both as academic disciplines and
- Dr. Hannah Wadsworth physical places for patient care.
(Neuropsychologist)
“I think there’s always challenges talking
When patients with PNES first begin between doctors. Sometimes a psychiatrist
experiencing seizures they are typically seen by a doesn’t really care what a neurologist says, or
neurologist. Inevitably, AEDs prove ineffective a neurologist doesn’t really care what a
and patients are referred to a tertiary epilepsy unit psychiatrist says and the minute you start going
for differential diagnosis. Video EEG (vEEG) off in your own jargon the other person turns
allows physicians to detect the presence or off.”
absence of epileptiform activity during a seizure - Dr. Scott Winder (Psychiatrist)
behavior. This method is widely regarded as thePage 5 of 12
Impulse: The Premier Journal for Undergraduate Publications in the Neurosciences
2021
Improving Behavioral Health Screenings in were diagnosed with clinical depression
Epileptic Populations increased from under 3% to over 25% (Friedman
Despite known comorbidity between et al., 2009). This reality – that almost a quarter
epilepsy and MI, standardized screening for of PWE who were regularly seeing a physician
psychiatric conditions in PWE has been for seizure maintenance had undiagnosed
practically non-existent (Kanner, 2003; Hanssen- depression – demonstrates a striking benefit to
Bauer et al., 2007). In a 2000 survey of 67 implementation of widespread, standardized
American neurologists, only 10% reported screening.
screening PWE for depression (Gilliam et al., “It’s very frequent that patients come in with
2004). Most physicians indicated this was due to the concern, but not the diagnosis yet.”
a perceived lack of evidence directly linking - Danielle Nolan, MD. (Pediatric
treatment of depression symptoms with improved Epileptologist at Beaumont Hospitals)
quality of life for epilepsy patients.
In recent years, the field of psychiatry
“The typical time elapsed between one has made considerable improvements in
[neuropsychological] evaluation and another is behavioral health screening and awareness
a year or more. So, it can be really challenging (Dawood et al., 2018). In contrast with the 2000
because essentially, we only have them four to survey, over 60% of neurologists who responded
five hours one day of the year. The majority of to a 2016 survey reported routinely assessing
that time is spent testing their cognition and PWE for depression symptoms and close to 50%
then getting basic information about their reported routinely assessing PWE for anxiety
mental health.” (Bermeo-Ovalle, 2019). An additional 15% of
- Dr. Hannah Wadsworth neurologist respondents conducted annual
(Neuropsychologist) psychiatric assessments in PWE (Bermeo-
Subsequent research has demonstrated Ovalle, 2019). While voluntary response rates
the impact of psychological health and can be inherently biased, mainstream attitudes
psychiatric treatment on epilepsy pathology towards the neurologist’s role in patient
(Ribot and Kanner, 2019) and quality of life for behavioral health have clearly shifted.
PWE/MI (Boylan et al., 2004; Kwon and Park,
2011). However, despite the existence of these Challenges Treating Psychiatric
data, there remain challenges in the systematic
application of screening practices.
Disorders in PWE
To improve detection rates, multiple
groups have developed rapid screening tools for Managing the Transition from Neurology to
common psychiatric comorbidities in PWE Behavioral Health
(Gilliam et al., 2004; Mbewe et al., 2013; “There’s definitely a lack of psychologists and
Micoulaud-Franchi et al., 2016). For instance, a psychiatric providers nationwide. You can get
2009 study assessed the application of rapid and them in, but there’s a long waiting list. Even
systematic mental health screening for epilepsy with our neuropsychologist, who only works
patients in Texas’ largest public hospital with these patients, there’s a waiting list of
(Friedman et al., 2009). In comparing diagnostic about 3-4 months to see her. I also utilize peer-
rates before and after implementation of a to-peer support groups, but I wish there were
validated depression screening tool, Friedman other groups I could refer my patients to.”
and colleagues observed significant - Dr. Danielle Nolan (Epileptologist)
improvements in the timeliness of psychiatric
diagnoses and referrals. Prior to this, providers After diagnosis of comorbid epilepsy and
were referring patients for psychiatric assessment psychiatric illness, collaborative relationships
only based on patient complaints and casual across disciplines remain critical to navigating
clinical observations. With standardized pharmacological treatment for both conditions.
screening in place, the proportion of PWE who However, access to psychiatry services remainsPage 6 of 12
The Comorbidity Between Epilepsy and Psychiatric Disorders: Assessing the Integration of Neuropsychiatric Care
2021
limited by the current nationwide shortage of survey, just under 60% of epileptologists reported
behavioral health professionals. The present that they were comfortable prescribing
demand for psychiatric care in the United States antidepressants and only 33% were willing to
greatly surpasses the number of practicing prescribe an anxiolytic (Bermeo-Ovalle, 2019).
psychiatrists, and this deficit is only projected to Similarly, Mula and colleagues found that close
worsen in the coming years (U.S. Department of to 50% of epilepsy care providers expressed
Health and Human Services, Health Resources aversion to prescribing antidepressants or anti-
and Services Administration, National et al., psychotics to PWE/MI (2017). One possible
2018). In urban areas, reported wait times for explanation is the artificial division of perceived
psychiatry are up to three months (Malowney et responsibilities created by our medical
al., 2014) and over half of rural counties in the establishment (Weller et al., 2014). While most
United States lack any prescribing behavioral neurologists are qualified to prescribe an anti-
health providers (Andrilla et al., 2018). depressant or anxiolytic regime before referring
to psychiatry, many still feel this responsibility
“Are we present enough in epilepsy? No. But falls outside of their professional silo (Sekhar and
we are spread so thin. We are often challenged Vyas, 2013).
just taking proper care of patients with
schizophrenia and bipolar disorder in the “We live in an accountable, and sometimes
community, let alone in more niche litigious society, where doctors get sued time.
environments.” All it takes is for a doctor to be a little too far
- Dr. Scott Winder (Psychiatrist) outside of her scope of practice, too far out on
the branch and the branch snaps. Then what?”
Another hurdle to treating psychiatric - Dr. Scott Winder (Psychiatrist)
symptoms in PWE/MI is a disconnect between
patients’ and neurologists’ preferred approach to Creating a space for behavioral health
treatment. Even when psychiatric prescribers are providers in both epilepsy centers and general
accessible, patients may not always want a neurology clinics would provide both patients
referral. In a recent survey of 63 PWE, patients and neurologists with an additional resource for
reported a 5:1 ratio preference for medication informing referrals and care management.
management by their current neurologist over a
psychiatric referral (Munger Clary and Croxton, “It really helps that we are in the same building
2021). It is unclear whether this preference is and I can just walk down the hall to talk to [our
mostly informed by practical concerns, neurologist].”
stigmatization of psychiatry, or something else - Dr. Angela DeBastos (Neuropsychologist)
entirely. If stigma informs this preference
(Anderson et al., 2015), involvement of
psychiatric providers in the care team could help Co-Management of Anti-Epileptic Drugs
patients feel more comfortable with mental health (AEDs) and Psychotropic Medication
services. The hesitancy to prescribe psychotropic
medications to PWE/MI can also be attributed to
“I think a lot of times the parents feel more the widespread concerns about lowering seizure
comfortable with the neurologists managing threshold. The effects of psychotropics in PWE
[psychiatric] medications because [the and their interactions with AEDs are still not fully
neurologist] knows the anti-seizure drugs best understood (Kanner, 2016a). Most AEDs have
and how to match those medications.” some risk of adverse behavioral side effects
- Angela DeBastos, PhD. (Pediatric (Chen et al., 2016) and, likewise, many
Neuropsychologist at Beaumont psychotropic medications present a risk for
Hospitals) neurologic complications (Haddad and Dursun,
2008).
In contrast to patient preferences, a large
proportion of neurologists remain reluctant to
prescribe psychotropic medications. In onePage 7 of 12
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2021
“[Knowing a patient has a comorbid are challenging to evaluate separately from
psychiatric condition] does cause me to tailor seizure activity. For instance, post-ictal anxiety
my seizure medication choices. I might lean and depression symptoms commonly seen in
towards a Depakote in a male or a Lamictal in epilepsy frequently fall short of meeting criteria
a female to help co-manage the epilepsy and for a separate psychiatric diagnosis. However,
the psychiatric concerns.” they are often correlated with interictal symptoms
- Dr. Danielle Nolan (Epileptologist) that would warrant a DSM diagnosis (Kanner et
al., 2004).
Though a select number of medications –
including some atypical antidepressants and “We spend so much time in training in learning
certain anti-psychotics – are associated with how do a good job at diagnosing and treating
increased seizure frequency, safety and benefit people with epilepsy that although we are also
for PWE/MI has been demonstrated with the trained to recognize when a patient may be
large majority of psychotropic drugs (Pisani et depressed or anxious, I don’t know that many
al., 2002; Habibi et al., 2016). Furthermore, both or most neurologists are equipped to directly
animal and human studies have provided treat these comorbidities.”
evidence to suggest a possible anti-epileptic - Dr. Nicholas Beimer (Epileptologist)
effect of selective serotonin reuptake inhibitor
(SSRI) antidepressants in conjunction with AED Deficits in self-perceived knowledge of
treatment in PWE/MI (Kanner, 2016c; Ribot et behavioral health among epileptologists
al., 2017). Similarly, several anti-convulsants – highlights a need for cross-training. A 2017
including gabapentin, valproate, carbamazepine, survey administered by the International League
topiramate, and lamotrigine – have demonstrated Against Epilepsy (ILAE) found that up to 50% of
therapeutic potential in treating both seizures and clinicians who treated PWE reported having poor
psychiatric symptoms (Nadkarni and Devinsky, or very poor knowledge of psychiatric
2005; Sepić-Grahovac et al., 2011; Prabhavalkar complications (Mula et al., 2017). Specifically,
et al., 2015). less than 50% of neurologists felt well-informed
There is currently little standardized regarding anxiety, disorders, mood disorders, or
guidance available to neurologists to help guide comorbid psychoses. There remains a deficit in
treatment with psychotropics. While there is an the literature regarding psychiatrist’s comfort
apparent need for more controlled trials with neurological comorbidities, however few
demonstrating safety and efficacy of these psychiatry residencies offer significant training in
medications in PWE, findings thus far have been the management of neuropsychiatric disorders
largely positive and support co-treatment of such as epilepsy (Shalev and Jacoby, 2019). This
seizures and psychiatric illness. This represents division in training makes it difficult for
yet another area of care where increased providers to address the intersection of comorbid
interdisciplinary collaboration between conditions when treating PWE/MI.
psychiatry and neurology would be of great Interdisciplinary fellowship training programs,
benefit to both patients and providers. such as those in behavioral neurology,
neuropsychiatry, and psychosomatic medicine,
provide an avenue to better understand reciprocal
The Future of Neuropsychiatric interactions between biology and behavior
Care (Arciniegas and Kaufer, 2006). These
subspecialties serve an important role in breaking
down silos. Still, few physicians choose to pursue
The divide between neurology and
this degree of specialization and many argue that
psychiatry begins with minimal cross-discipline
the diversity in training contributed by the
training. As previously mentioned, diagnostic
separation of neurology and psychiatry benefits
standards for psychiatric disorders are complex
the patient care team (Perez et al., 2018).
and difficult to navigate, even for experts in the
field. For neurologists without specific training in
this area, psychiatric and behavioral symptomsPage 8 of 12
The Comorbidity Between Epilepsy and Psychiatric Disorders: Assessing the Integration of Neuropsychiatric Care
2021
“It’s a hard sell to get people to do a fellowship demands time, energy, and a degree of health
and it’s a hard sell to get psychiatrists to do a literacy that is uncommon in the general
fellowship like [psychosomatic medicine].” population.
- Dr. Scott Winder (Psychiatrist) E. E. Reasoner has first-hand experience
with many of these challenges from my own
As an alternative to completely merging family’s efforts to coordinate care for my sister.
two fields, physicians from both circles have Although we have compassionate and
sought to emulate aspects of neuropsychiatric knowledgeable physicians dedicated to my
fellowships, including multidisciplinary sister’s care, too many unanswered questions
mentorship, transdiagnostic procedures, and remain. As a result, we are always left wondering
development of a shared clinical language during if there is more that we could do to improve her
residency (Selwa et al., 2006; Kanner, 2014; health outcomes and quality of life.
Perez et al., 2018). By cultivating a deeper The aim of this review was to identify the
understanding of the perspectives and practices source of existing hurdles to integrated care, why
carried out by the other discipline, physicians will these hurdles remain in place, and to identify
hopefully become more comfortable exerting strategies to eliminate these hurdles. Prior to this
flexibility in their roles and collaborating on investigation, I was confident that health
patient care. professionals could make simple changes to
improve patient outcomes; in my idealistic
mindset a neurologist who suspects psychiatric
Reflections & Conclusions symptoms in PWE should immediately work to
resolve that distress. However, it became readily
The growing body of literature on apparent that, while individual physicians can
diagnosing and treating PWE/MI is encouraging. facilitate positive change in access to quality
Yet, the current process of securing and care, the composition of the care team, cross-
maintaining mental health care in coordination discipline training, and the structure of our health
with neurology generates considerable stress for care system means that change is anything but
PWE / MI and their families. Patients are simple.
frequently misdiagnosed and urgent needs are Even as our understanding of
met with delays. Furthermore, PWE/MI are neurological and psychiatric disorders reveal
assaulted by both internal and external stigma – more similarities than distinctions, the structural
at times from their own well-intentioned care divide between medical specialties remains
providers. steadfast. That integrative care remains rare
despite evidence and motivation on the part of
“My hope would be that most physicians – no
patients, families, and providers alike shows that
matter what your specialty is if you’re involved
change must begin at the structural level for real
in direct patient care – would be capable of
progress to be made. Red tape of institutional and
diagnosing and managing psychiatric diseases
insurance policies and the current shortage of
like depression and anxiety. It’s important to
behavioral health providers must be addressed.
recognize early when people are doing well
The disciplinary divide in medicine must be
and then when they’re not. That’s the time to
reframed to reflect the biological relationship
be referring to [a mental health professional].”
between neurological and psychiatric symptoms.
- Dr. Nicholas Beimer (Epileptologist) Importantly, many neurologists and psychiatrists
are pushing for evidence-based structural
Even when a patient’s case is seemingly changes through inter-professional advocacy,
well-managed by individual providers, treatment political lobbying, and pioneering research
recommendations for the patient’s epilepsy and studies.
comorbid psychiatric illness can be disjointed. As our understanding of the bidirectional
When neurology and psychiatry are operating link between epilepsy and mental illness unfolds,
independently, responsibility of connecting the it is essential that institutions embrace the
dots is left to patients and their families. This integration of neuropsychiatric care to guidePage 9 of 12
Impulse: The Premier Journal for Undergraduate Publications in the Neurosciences
2021
future progress in patient outcomes and quality of Association Committee on Research, J
life. Neuropsychiatry Clin Neurosci 33:27–42.
Baslet G, Dworetzky B, Perez1 DL, Oser M
(2015) Treatment of psychogenic
Acknowledgements nonepileptic seizures: Updated review and
findings from a mindfulness-based
We would like to thank Drs. Nicholas Beimer, intervention case series, Clin EEG Neurosci
Angela DeBastos, Danielle Nolan, Scott Winder, 46:54–64.
and Hannah Wadsworth for sharing their Beimer, NJ (May 26, 2020) Interview about
experience in this topic and adding to the care management of patients with epilepsy
dialogue. This article was the product of an and comorbid mental illnesses. Conducted
Honors Senior Project through the Frederik
Meijer Honors College at Grand Valley State
via Zoom by Reasoner E.
Berg AT, Loddenkemper T, Baca CB (2014)
University. Finally, the authors dedicate this
Diagnostic delays in children with early onset
work to the memory of Dr. Chelsea Boet, a
epilepsy: Impact, reasons, and opportunities
lifelong patient advocate without whom this
to improve care, Epilepsia 55:123–132.
paper would not exist.
Bermeo-Ovalle A (2019) Psychiatric
comorbidities go untreated in patients with
Corresponding Author epilepsy: Ignorance or denial?, Epilepsy
Behav 98:306–308.
Erin Reasoner Boylan LS, Flint LA, Labovitz DL, Jackson SC,
University of Iowa Hospitals and Clinic Starner K, Devinsky O (2004) Depression but
erin-reasoner@uiowa.edu not seizure frequency predicts quality of life
200 Hawkins Drive, T206-GH in treatment-resistant epilepsy, Neurology
Iowa City, IA 52242 62:258–261.
Calle López Y, Ladino LD, Benjumea Cuartas
V, Castrillón Velilla DM, Téllez Zenteno
JF, Wolf P (2019) Forced normalization: A
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